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HomeMy Public PortalAbout6273 AVON AVE_Electrical_2/25/1992_ WORKERS' COMPENSATION DECLARATION 76A669DPW3/87 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self cE 806G insuse, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certifie4 copy thereof (Sec. 3800, La C.) Policy No. `. ( Company Lb`(C FOR APPLICANT TO FILL IN JOB A-yt1 rA/ ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH o NO. FEE ADDRESS Krtified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY n Aepfrtment. Multi-family Sq. Ft. NEARESTCROSS ST. flo Date Applicant l[el— o Residential Swimming Pools OWNER OR F�/ j FIRM NAMEA 1A �-[ 61C CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light / Sw.— MAIL COMPENSATION INSURANCE First 20 ADDRESS ' (Thislsection need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total.No. CITY Tel. No. Date Applicant NOTICE TO APPLICANTFixed Appliances Not Over 1 HP PERMIT: If, after making this Certificate of Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer _M.— r ADDRESS p S 011 �� with comply with such provisions or this permit shall .be Top — FAU W.H. — / deemed revoked. CITY V kA Tel. No. l Hood Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR 0 2'2 O I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBERClass. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY >- and Professions Code,and my license is in full force/and ffect. p 11 L Size &Type HP, KW, KVA, or KVAR j� O —� s�� 0 License Number �jf Lic. Class Up to 1 Incl. FINAL U Contractor r V Date 2 Z Over 1 to 10 Incl. DATE �! �7� VALIDATION Cr F-1 Over 10 to 50 Incl. FINAL % ! F•- I am exempt under Sec. Over 50 to 100 Inc. U BY 100 0- B.&P.C. for this reason Over a Services, Swbd.; MCC & Ponelboards Z Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V _ Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances _ HOME OWNER-BUILDER DECLARATION :; Sign with One Branch Circuit AC, IrI I hereby affirm that I am exempt from the Contractor's License -•:-:••-t Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits - Professions Code): [f ❑ Misc. Conduits&Conductors I, as owner of the property, will do the work and.the structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). ► s:, jNay'' CONSTRUCTION LENDING AGENCY {•l;r•• sl 1 ; I hereby affirm that there is a construction lending agency for ':I I•is'e'•s� the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) g (Sec. 3097, Civ. C.). PLAN CHECKING-FEE +_* l i!)-i 's ?!x Lender's Name _ PERMIT ISSUING FEE a M .; Lender's Address I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the abov -me tone roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Ss nature of e ittee Date ©s